Medical records—common abbreviations
Produced in partnership with Andrew Ritchie QC of 9 Gough Chambers
Medical records—common abbreviations

The following PI & Clinical Negligence practice note Produced in partnership with Andrew Ritchie QC of 9 Gough Chambers provides comprehensive and up to date legal information covering:

  • Medical records—common abbreviations

°Not Present or No abnormality (e.g. J° “No jaundice”)
+/-Uncertain/equivocal
+Present or Noted
++Present Significantly
+++Present in Excess
#Fracture
Increasing, up
Constant, normal
Decreasing, down
Diagnosis
Diff.▵ OR ▵▵Differential Diagnosis
=Equivalent to
3OK or satisfactory
1/7One day
2/52Two weeks
3/12Three months
A or AJAnkle Jerk/Reflex
AAAAbdominal Aortic Aneurysm
AALAnterior Axillary Line
ABGArterial Blood Gas
ACLAnterior Clavicular Line OR Anterior Cruciate Ligament
A.dAs Directed
A/EAir Entry to Lungs OR Accident & Emergency
AFAtrial Fibrillation
AFBAcid Fast Bacillus
AFPAlpha-fetoprotein
AI/RAortic Incompetence/Regurgitation
AoRAortic Valve Replacement
ASAbdominal System OR Aortic Stenosis
ATCHAdrenocorticotrophic hormone
A/VAnteverted
AXRAbdominal X-Ray
bd/bidTwice a Day
B or BJBiceps Jerk/Reflex
BCCBasal Cell Carcinoma
BMIBody Mass Index
BNOBowels Not Opened
BORBowels Open Regularly
BPBlood Pressure or British Pharmacopoeia
BPdDiastolic Blood Pressure
BPsSystolic Blood Pressure
BSBreath Sounds or Bowel Sounds or Blood Sugar
C2H5OHAlcohol
CA or CaCarcinoma Cancer
CABG/S or CAG/SCoronary Artery (Bypass) Graft/Surgery
CFSChronic Fatigue Syndrome
CNSCentral Nervous System
C/o or C.oComplains of
CO2Carbon Dioxide
COADChronic Obstructive Airways Disease
COPDChronic Obstructive Pulmonary Disease Chronic Lung Disease
CPDCephalo-Pelvic Disproportion
CSFCerbro-Spinal Fluid
CT or CATComputerised Axial Tomography
CVACerebrovascular Accident Stroke
CVSCardiovascular System
CX or CxCervix OR Cervical Spine
CXRChest X-ray
D&VDiarrhoea and Vomiting
D/HDrug History
DIP, PIPDorsal/Proximal Interphalangeal Joints
DLEDiscoid Lupus Erythematosus
DNADid Not Attend
DOADead On Arrival
DSDisseminated (Multip
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